Dr. María Susana Ciruzzi
Lawyer, specializing in criminal law and bioethics; Associate Director of Legal Affaris, Prof. Dr. Juan P. Garrahan Pediatrics Hospital, Buenos Aires, Argentina
The first issue I would like to address has to do with the “definitions” section. In a recent article, published in the Journal of Medical Ethics1 it seems to introduce a new option at the end of life and that is closely related to palliative sedation used in palliative care (PC), although its objective saeems to be aim at causing the death of the patient and as a means of guaranteeing medical aid in dying ( MAID). I think it will be necessary to address this issue to establish a clear difference between the use of palliative sedation and the expanded use of it, as they call it in the article.
The good news is that 48% of those surveyed said that palliative care professionals must be involved in the discussion of medical assistance in dying, even though 70% reject euthanasia and assisted suicide as being part of palliative care.
The response rate is a little low (25%) with participants from around one-third (66) of countries in the world involved. 55% reported that a debate is taking place in their countries, which means that their prohibition is under review, either from a merely legislative criterion or from a medical/professional criterion.
Half of those surveyed said that the debate in some way helps the development of palliative care, while 61% believe that it brings confusion to the community and health care decision-makers and 40% said it hinders the development of palliative care by shifting the focus toward euthanasia and/or assisted dying. In my opinion, this is one of the great debates in the context of palliative care. Perhaps one approach is to analyze what has happened to palliative care in those countries that have allowed some form of MAID.
There is almost a tie between those who said that these practices should be available (49%), albeit most of those respondents agreed that it be available for exceptional cases only (56%), and those who said they should not (45%). In my opinion, this polarization is counterproductive for any scientific approach—both from medical and human sciences. Presenting the issue as "all or nothing" or "for/against” is more appropriate to measure the love for a football team than to a technique-based position. I think that these dichotomous approaches, as well as the binomial expressed by "it's good/it's wrong," does not allow us to advance in a mature, sincere, committed, and well-founded analysis of these alternatives.
It is interesting to compare the position that palliative care is enough to address the multiplicity of factors and needs that arise at the end of life, to those who doubt such a statement or who consider that individual autonomy must have some role in the issue, but without subjugating professional autonomy (conscientious objection). This demands a very special balance that, for the moment, seems difficult to achieve.
The majority of those surveyed have had five or fewer requests for euthanasia, assisted dying, or hastened death in their professional life, while between 20% and 40% have never had a single similar request. This number of requests for assisted death perhaps shows us the low incidence that it can have in daily practice. However, it does not necessarily mean that these options lack medical, legal, or social interest, or relevance.
Gilberston L, Savulescu J, Oakley J, Wilkinson D. Expanded Terminal Sedation in End-of-Life Care. J Med Ethics. Published online December 21, 2022. DOI: 10.1136/jme 2022-108511